Locoregional Therapies for the Treatment of Hepatic Metastases from Breast and Gynecologic Cancers

Chemoembolization, Radioembolization, and Percutaneous Ablation: New Opportunities for Treating Ovarian Cancer Liver Metastasis

OPINION STATEMENT

Parenchymal liver metastases from ovarian cancer, occurring in 2-12.5% of cases, significantly worsen prognosis. While surgery and systemic treatments remain primary options, unresectable or chemotherapy-resistant multiple liver metastases pose a significant challenge. Recent advances in liver-directed therapies, including radiofrequency ablation, microwave ablation, cryoablation, transarterial chemoembolization (TACE), and radioembolization, offer potential treatment alternatives. However, the efficacy of these techniques is limited by factors such as tumor size, number, and location. The ideal candidate for tumor ablation is a patient with paucifocal disease, a single tumor up to 5 cm or up to 3 tumors smaller than 3 cm and tumors 1 cm away from major bile ducts and high-flow vessels. Transarterial chemoembolization could be performed in patients with less than 70% tumor load. Differently, radioembolization is available with less limitation on the sites or number of liver cancers. Radioembolization techniques are also able to downsize liver metastases. However, there are limited data regarding the outcomes of loco-regional therapy in patients with hepatic metastases from ovarian cancer. Advancing liver-directed therapies through interventional oncology, combined with robust data on the oncological efficacy of these local treatments, will validate their potential as effective locoregional therapies for liver metastases. This could offer a promising treatment option for patients with ovarian cancer and unresectable hepatic metastases.

Outcomes Analysis of Yttrium-90 Radioembolization for Tumors Other Than Metastatic Colorectal Cancer from the Radiation-Emitting SIR-Spheres in Nonresectable (RESiN) Registry

PURPOSE

To characterize the response and survival outcomes of yttrium-90 (90Y) transarterial radioembolization (TARE) for unresectable, liver-dominant metastases from primary neoplasms other than colorectal carcinoma.

MATERIALS AND METHODS

This study included 1,474 patients enrolled in the Radiation-Emitting Society of Interventional Radiology (SIR)-Spheres in Nonresectable Liver Tumor registry who received resin 90Y-TARE as part of their oncologic management for unresectable primary or secondary liver tumors (NCT02685631). Of these patients, 33% (481/1,474) were treated for liver metastases of noncolorectal origin (m-non-CRC) compared with 34% (497/1,474) treated for metastatic colorectal cancer (mCRC) and 34% (496/1,474) treated for hepatocellular carcinoma. Treatment response and cancer survival probabilities were computed and compared for each primary cancer type. The Kaplan-Meier method and log-rank test were used to compare survival outcomes.

RESULTS

Radiological responses were observed in 12 unique cancer types, mostly heavily pretreated malignancies refractory to multiple lines of systemic therapies. The overall use of resin 90Y-TARE in m-non-CRC resulted in better treatment outcomes in terms of duration of response, progression-free survival, time to progression, and overall survival (P = .04, P = .02, P = .01, and P = .04, respectively). Analyses of cancer cell types revealed that metastatic neuroendocrine tumor, sarcoma, and ovarian, renal, prostate, and breast cancers were associated with superior treatment outcomes, whereas worse treatment outcomes were observed in metastatic lung, gastric, pancreatic, and esophageal cancers.

CONCLUSIONS

Real-world data demonstrate the use of resin 90Y-TARE in m-non-CRC refractory to standard chemotherapy. For some cell types, this expanded use achieved superior treatment outcomes relative to the reference standard of mCRC, suggesting the need for inquiry into broadened indications for 90Y-TARE.

Chemoembolization Beyond Hepatocellular Carcinoma: What Tumors Can We Treat and When?

Liver metastases are the most common malignancy found in the liver and are 20 to 40 times more common than primary hepatic tumors, including hepatocellular carcinoma. Patients with liver metastases often present with advanced disease and are not eligible for curative-intent surgery or ablative techniques. The unique hepatic arterial blood supply of liver metastases allows interventional radiologists to target these tumors with transarterial therapies. Transarterial chemoembolization (TACE) has been studied in the treatment of liver metastases originating from a variety of primary malignancies and has demonstrated benefits in terms of hepatic progression-free survival, overall survival, and symptomatic relief, among other benefits. Depending on the primary tumor from which they originate, liver metastases may have different indications for TACE, may utilize different TACE regimens and techniques, and may result in different post-procedural outcomes. This review offers an overview of TACE techniques and specific considerations in the treatment of liver metastases, provides an in-depth review of TACE in the treatment of liver metastases originating from colorectal cancer, neuroendocrine tumor, and uveal melanoma, which represent some of the many tumors beyond hepatocellular carcinoma that can be treated by TACE, and summarizes data regarding when one should consider TACE in their treatment algorithms.

Ultrasound Image-Based Radiomics: An Innovative Method to Identify Primary Tumorous Sources of Liver Metastases

OBJECTIVES

To develop radiomic models of B-mode ultrasound (US) signatures for determining the origin of primary tumors in metastatic liver disease.

METHODS

A total of 254 patients with a diagnosis of metastatic liver disease were included in this retrospective study. The patients were divided into 3 groups depending on the origin of the primary tumor: group 1 (digestive tract versus non-digestive tract tumors), group 2 (breast cancer versus non-breast cancer), and group 3 (lung cancer versus other malignancies). The patients in each group were allocated to a training or testing set (a ratio of 8:2). The region of interest of liver metastasis was determined through manual differentiation of the tumors, and radiomic signatures were acquired from B-mode US images. Optimal features were selected to develop 3 radiomic models using multiple-dimensionality reduction and classifier screening. The area under the curve (AUC) of the receiver operating characteristic curve was applied to assess each model's performance.

RESULTS

A total of 5936 features were extracted, and 40, 6, and 14 optimal features were sequentially identified for the development of radiomic models for groups 1, 2, and 3, respectively, with training set AUC values of 0.938, 0.974, and 0.768 and testing set AUC values of 0.767, 0.768, and 0.750. The differences in age, sex, and number of liver metastatic lesions varied greatly between the 4 primary tumors (P < .050).

CONCLUSIONS

B-mode US radiomic models could be effective supplemental means to identify the origin of hepatic metastatic lesions (ie, unknown primary sites).

Safety and Efficacy of Arterially Directed Liver Therapies in the Treatment of Hepatic Metastatic Ovarian Cancer: A Retrospective Single-Institution Study

PURPOSE

To evaluate the safety and efficacy of 2 locoregional therapies (LRTs) including hepatic artery embolization (HAE) and transarterial radioembolization (TARE) in the treatment of patients with metastatic ovarian cancer to the liver.

MATERIAL AND METHODS

From October 2010 to May 2019, the data of 15 consecutive patients (median age, 54 years ± 9.8; range, 35-78 years) with hepatic metastatic ovarian cancer who were treated with either HAE (n = 6; 40%) or TARE (n = 9; 60%) were reviewed. The most common histopathologic type was epithelial ovarian carcinoma (80%). The most common chemotherapy regimens used prior to embolization included carboplatin, paclitaxel, cisplatin, and bevacizumab. Patients received a mean of 4 lines ± 3 (range, 1-9) of chemotherapy. All patients with serous carcinoma were resistant to platinum at the time of embolization. Indications for embolization were progression of disease to the liver while receiving chemotherapy in 14 (93.3%) patients and palliative pain control in 1 patient.

RESULTS

The overall response rates at 1, 3, and 6 months were 92.4%, 85.6%, and 70%, respectively. Median overall survival from the time of LRT was 9 (95% confidence interval [CI], 4-14) months. Median local tumor progression was 6.4 months ± 5.03 (95% CI, 3.3-9.5). No grade 3-5 adverse events were detected in either group.

CONCLUSIONS

HAE and TARE were well tolerated in patients with metastatic ovarian cancer to the liver and possibly ensured prolonged disease control in heavily treated, predominantly in patients resistant to platinum. Larger numbers are needed to verify these data.

Hepatic Metastasis from Breast Cancer

Breast cancer is the most common cancer in women and breast cancer liver metastasis may be associated with poor outcomes. Emerging locoregional therapies can be given in outpatient settings or with short hospital stays, to provide local control, support quality of life, preserve liver function, and potentially prolong survival. This review discusses retrospective studies suggesting potential benefits of locoregional treatment of breast cancer liver metastasis. Future prospective studies are needed to demonstrate efficacy and optimize patient selection.

Interventional Oncology Approach to Hepatic Metastases

Metastatic liver disease is one of the major causes of cancer-related morbidity and mortality. Locoregional therapies offered by interventional oncologists alleviate cancer-related morbidity and in some cases improve survival. Locoregional therapies are often palliative in nature but occasionally can be used with curative intent. This review will discuss important factors to consider prior to palliative and curative intent treatment of metastatic liver disease with locoregional therapy. These factors include those specific to the tumor, liver function, liver reserve, differences between treatment modalities, and patient-specific considerations.

Comparison of hepatic resection and systemic treatment of breast cancer liver metastases: A propensity score matching study

BACKGROUND

The role of surgery in breast cancer liver metastases (BCLM) remains elusive, and current application is limited. Our aim is to investigate whether hepatic resection (HR) of BCLM improves survival compared with non-hepatic resection (NHR) treatment.

METHODS

Three hundred and eighty-four patients with BCLM from 2008 to 2018 were divided into two groups. Propensity score matching (PSM) analysis was used to compare the clinical outcomes.

RESULTS

After PSM the mean overall survival (OS) and the 1, 3, and 5-year OS rates in HR group were 61.8 months, 92.6%, 54.7% and 54.7%, respectively; while for NHR group these values were 38.6 months, 79.2%, 45.6% and 21.9%, respectively (p < 0.007). Multivariate analysis indicated hormonal receptor status (p = 0.039) and hepatic resection (p = 0.032) were independent prognostic factors.

CONCLUSION

Our study revealed that hepatectomy yields a survival benefit safely compared with medical treatments, especially for patients with positive hormonal receptors.

Intra-arterial Mitomycin C infusion in a large cohort of advanced liver metastatic breast cancer patients: safety, efficacy and factors influencing survival

PURPOSE

The aim of this study was to determine the safety and efficacy of Mitomycin C (MMC) infusion in a large cohort of advanced liver metastatic breast cancer patients (LMBC) and to determine factors influencing overall survival (OS).

METHODS

We retrospectively analysed LMBC patients, treated with MMC infusion between 2000 and 2017. Hepatic response was measured with baseline CT scans and first available CT scan after MMC infusion by RECIST 1.1 criteria. Adverse events were registered by the CTCAE version 5.0. OS and hepatic progression free survival (hPFS) were evaluated using Kaplan-Meier estimates. After univariable analysis, a stepwise forward multivariable (MV) prediction analysis was developed to select independent pre-treatment factors associated with OS.

RESULTS

We included 176 patients with a total of 599 MMC infusions, mostly heavily pre-treated patients with a median time from diagnosis of MBC to MMC infusion of 36.9 months. RECIST evaluation of liver lesions (n = 132) showed a partial response rate of 15%, stable disease of 43% and progressive disease in 17%. Adverse events grade 3 and 4 were reported in 17.5%. Median PFS was 5.5 months and median OS was 7.8 months. Significant independent baseline predictors of worse OS included number of prior systemic chemotherapy lines, prior liver ablation, higher liver tumour burden and elevated levels of bilirubin and ALT.

CONCLUSION

MMC infusion is safe and effective in advanced LMBC patients. An increased number of prior therapies, a higher liver tumour burden and elevated levels of bilirubin and ALT were associated with a worse OS.